Statutory Declaration for
Assignment - Individual
Operations Division
CANADA
Proposed Assignment of
IN THE MATTER OF
PROVINCE OF ALBERTA
(Type of Disposition)
TO WIT
I,
(Name)
of
,
(Full Address)
,
(Province)
(Postal Code
Telephone:
(Home)
(Business)
Email Address:
do solemnly declare:
1) I am a Canadian Citizen or permanent resident within the meaning of the Immigration and Refugee Protection
Act (Canada).
2)
I am
years of age.
3)
I am a Provincial Government employee.
Yes
No
If yes, please provide clearance of conflict of interest from the Deputy Minister of your department in accordance
with Section 24 of the Public Service Act. Please attach this clearance to the Statutory Declaration.
My relationship to the assignor is:
Husband
Wife
Son
Daughter
Father
Mother
Brother
Sister
Father-in-law
Mother-in-law
Son-in-law
Daughter-in-law
Nephew
Niece
None of the above
Adult Interdependent Partner (within the meaning of Sec 3(1) of the Adult Interdependent Relationships Act)
4)
I hereby assume full responsibility for the payment of all municipal, county, or improvement district taxes heretofore
levied against all land(s) covered by the proposed assignment which remain unpaid and for the payment of all taxes
responsibility notwithstanding that I may not have been in possession of these lands when they were assessed and
placed on the assessment roll by the municipality.
I agree to perform and uphold all conditions of any range improvement agreement or resource management
operational plan that may form part of this disposition.
I am aware that the acquisition of a disposition on these public lands does not convey the right to graze bison. In
order to graze bison on these public lands, additional written authorization from Environment and Parks is required.
And I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as
if made under oath and by virtue of the Canada Evidence Act.
Declared before me at the
of
in the province
of
,
this
day of
, 20
A Commissioner for Oaths in and for the Province of Alberta
_________________________________________________
Signature (Assignee)
Printed or stamped name of Commissioner for Oaths and date on
which appointment expires
Information you provide to Alberta Environment and Parks (AEP) is collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP)
Act and is managed in accordance with Part 2 of the FOIP Act. The personal information you provide will be used by AEP for the purpose of administering the Public Lands Act
and its associated regulations. Your personal information will not be used for any other purpose by AEP without your consent; however, it may be publicly disclosed to anyone
requesting access of the record in accordance with Sections 166-167 of the Public Lands Administration Regulation.
Sep 28, 2015
Lands - Statutory Declaration for Assignment – Individual LD 05
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